DOI: https://doi.org/10.21203/rs.3.rs-1880946/v1
Background: Standard precautions are minimum infection control practices used to prevent the transmission of diseases and apply to all patient care. Nursing students are at high risk of exposure to occupational biologic hazards because they are obligated to provide care to patients admitted with unknown infection statuses. compliance with standard precautions is an effective and efficient means of infection prevention. However, their compliance with standard precautions among nursing students is not known in Ethiopia. therefore, this study aimed to assess compliance with standard precautions and associated factors among undergraduate BSc nursing students at governmental universities in the Amhara region, northwest Ethiopia, 2021.
Methods: Institutional-based cross-sectional study was conducted among undergraduate BSc nursing students at the governmental universities of Amhara region, northwest Ethiopia from April 15 to May 15, 2021. A simple random sampling technique was used to select 423 samples. Then data were entered into Epi-info version 7 and exported to SPSS version 25.0 for analysis and descriptive statistics were presented in text, tables, and charts. Bivariable and multivariable logistic regression was computed and P-value < 0.05 was considered to identify statistically significant factors.
Result: The response rate of the study was 97.9 % (414). Good compliance of nursing students towards standard precautions was 56.3% with (95%CI =51.4 - 60.9), which is significantly associated with good knowledge (AOR =2.519, 95 % CI =1.609-3.943)), perceived safe workplace climate (AOR = 2.147, 95 % CI= 1.242-3.7121) and training or seminar related to standard precautions in the last six months (AOR = 1.518, 95 % CI= 1.008-2.288).
Conclusion: The overall compliance of nursing students with standard precautions was low. The major factors associated with good compliance were good knowledge, a perceived safe workplace, and having seminars or training in the last six months. Training, enhancing knowledge, and creating a safe hospital environment are recommended to improve nursing students’ compliance with standard precautions.
Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered(1–3). It is designed to protect healthcare professionals and patients from exposure to potentially infected blood and body fluids except for sweat (4).
Nowadays the most common adverse effects in health care worldwide are Health Care-Associated Infections (HCAIs), which endanger the health of both patients and health care staff (5). Each year a hundred million patients (6, 7) and 3 million HCWs are affected with HCAIs (8).
Being compliant with SPs among health care providers reduces the risk of HCAIs by one-third(9). However, globally a review revealed that compliance of HCWs to SPs is suboptimal, with a compliance rate of less than 50% (10). Even if limited studies are found in the world other than Ethiopia among nursing student's compliance with SP, Some studies in Croatia, South Korea, and Saudi Arabia, revealed that their compliance level is not good (11–14).
Nursing students (NSs) are at high risk of workplace exposure to biological hazards since they are expected to provide treatment for patients of uncertain infection status and due to their underdeveloped abilities and lack of knowledge in the clinical setting (11, 15–18). In particular, they are at high risk of acquiring blood infections, such as HIV infection (19), viral hepatitis (20), and other infectious diseases, like tuberculosis (21). One study in Ethiopia revealed that more than half and one-third of nursing and midwifery students having needle stick injuries and exposure to blood and other body fluids respectively (22).
Nursing student's compliance with SPs is affected by age, sex marital status, knowledge, attitude, practicum department, previous blood, and body fluids exposure, safety climate, and training on SPs (11–14, 23, 24).
Nursing interventions often require touching the patients, which can facilitate cross-contamination if they fail to comply with proper infection prevention guidelines (25). Having good compliance with standard precautions protects nursing students from occupational exposure to blood and body fluid, and lowers the risk of infection transmission to them and patients (26, 27). However, compliance and associated factors towards standard precautions among undergraduate nursing students in Ethiopia are not known. As a result, this study aims to assess compliance and associated factors towards standard precautions among nursing students in governmental universities of the Amhara region, northwest Ethiopia.
An institutional-based cross-sectional study design was conducted from April 15 to May 15, 2021, at governmental universities of the Amhara region, northwest Ethiopia,2021. Amhara region is one of the ten regions in Ethiopia and is located in the Northwest part of Ethiopia. Its Capital city is Bahir Dar, which is located 565 km from Addis Ababa, the capital city of Ethiopia. There are 10 governmental universities in the region, among these universities of which 6 are found in northwest Ethiopia. Among these universities, Bahir Dar (BDU), Debretabor (DTU), Debre Markos (DMU), and the University of Gondar (UOG) have a college of health science and teach nursing students and are included in the study. There were a total of 738 nursing students of the third and fourth year in selected universities. However, first-year and second-year nursing students were not yet joining the universities and the nursing schools because of the COVID-19 interruption of the learning-teaching process in Ethiopia.
All third-year and fourth-year undergraduate nursing students who were learning at the four Governmental Universities of Amhara Region, northwest Ethiopia, 2021.
All third-year and fourth-year undergraduate nursing students who were learning at the four Governmental Universities Amhara Region, northwest Ethiopia and available during the data collection period, 2021.
All third-year and fourth-year undergraduate nursing students who were on education, volunteer, and available during data collection time.
The sample size was determined by using single population proportion formula using 95% confidence level (Z = 1.96), degree of precision (marginal error) = 5%, and proportion (p = 50%\(n=\frac{{z}^{2}*p(1-p)}{{d}^{2}}\)
Where; n = the required sample size
P = proportion of nursing students; 50%=0.5 (since there was no previous study in Ethiopia)
z = degree of accuracy at 95%=1.96
d = margin oferror = 0.05\(\)
\(n=\frac{\left({1.96)}^{2}*0.5\right(1-0.5)}{{\left(0.05\right)}^{2}}\) =384
None response 38.4 ≈ 39(10%). The final sample size was 423
The list of nursing students was taken from the four universities’ nursing departments. For each university, proportionate allocation was used, with UoG = 171, DTU = 72, BDU = 119, and DMU = 61. For each academic year and program at each university, a proportional allocation was used. Then, from each academic year and program, each class was given a proportionate allocation. Finally, participants from each class were chosen using a simple random sampling technique.
Standard precautions
it is a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any settings in which health care is delivered(2). For this study among the components of SP prevention of cross-infections, PPE usage, disposal of sharps and wastes, decontamination of spills and used articles, and prevention of cross-infection will be included in this study.
Compliance is defined as the extent to which certain health care practices are implemented following known recommendations (28).
Compliant (Good compliance); if a study participant scores greater than or equal to the median (11) score of compliance questions.
Noncompliant (Poor compliance)
if a study participant scores less than the median (11) score of compliance questions.
Good knowledge
Study participant scores greater than or equal to a median (7) score of question regarding knowledge on standard precautions.
Poor knowledge
Study participant scores less than the median (7) score of question regarding knowledge on standard precautions.
Positive attitude
Study participant scores greater than or equal to the median ((22) score of attitude questions.
Negative attitude
Study participant scores less than the median (22) score of attitude questions.
Safe workplace climate
if the respondent scores greater than or equal to the median (5) score of safety questions.
Unsafe workplace climate
if the respondent scores less than the median (5) score of safety questions.
Data were collected using a self-administered structured questionnaire to obtain information from participants. The questionnaire is divided into three parts. Part I asked for Socio-demographic variables and has 13 questions. Part II has the Compliance with Standard Precautions Scale (CSPs). The CSPS is a 20-item scale that assesses self-reported compliance with SPs. The scale’s items evaluate compliance with the use of PPE (6 questions), disposal of sharps (3 Questions) disposal of wastes (1 question), decontamination of spills and used articles (3 questions), and prevention of cross-infection (7 questions). The response set is a 4-point Likert scale that consists of responses such as (‘‘never’’, = 1 ‘‘seldom’ =2’sometimes’’=3, and ‘‘always’’=4 during data collection .it was also recoded into 1 and 0. A score of 1 is interpreted as an ‘‘always’’ response, while 0 is applied for the other responses. A total range score of 0—20 is expected, with higher scores signifying better compliance with SPs. Items 202, 204, 206, and 215 are negatively stated; thus, scores were reversed before computations. The tool is adapted from Hong Kong (27). Part III had questions of factors affecting compliance of nursing students and it has three sections. Section I, Knowledge questions which had 10 multiple choice questions, Section II is attitude questions which had 7 questions with 5 points Likert scale (1 = strongly disagree,2 = disagree, 3 = Undecided4 = Agree and 5 = strongly agree. section III is safety climate questions, which had 7 yes or no responses. Knowledge, attitude, and safety climate questions were adapted from tools used for HCWs in Ethiopia and Korea (29, 30). study participants were approached in each ward unit.
Eligible nursing students in specified classrooms were selected based on inclusion criteria, after getting informed consent the data collector was administered the questionnaire. Participants were provided with appropriate information about the study, then informed consent was being obtained to assure their willingness to participate in the study. Four trained BSc nurses collected the data and four trained MSc nurses closely followed the data collection process.
To ensure the quality of data one-day training was given to data collectors and supervisors regarding the structured tool (on the objective of the study and how to collect the data). A week before starting the actual period, the questionnaire was pretested in Weldiya University on 10% of the total sample size of nursing students, and the necessary correction was done. Internal consistency was checked by computing Cronbach’s α for the dependent variable was 0.709 from the pretest data. Regular daily supervision was done to check, the consistency and completeness of the filled-out checklist format, by the principal investigator. After the actual data collection process, the collected data were cross-checked for questionnaires' consistency and completeness.
Data were coded and entered into Epi-info version 7 and then it was exported to SPSS version 25 for analysis. Data entry was made by the principal investigator. Descriptive statistics including, frequencies, proportions, mean, median and SD was computed and displayed by using tables, graphs, and texts. The model fitness was checked by Hosmer and Lemeshow goodness of fit test and its p-value was 0.716. Multicollinearity was checked
Bivariable and multivariable logistic regression analysis was computed to examine the association between the dependent variable and independent variables. Those with p < 0.05 at multivariable logistic regression analysis were considered statistically significant.
The data were collected from a total of 414 randomly selected participants with a response rate of 97.8%. Of the total respondents, 221 (53.4%) were males. The median age of the participants was 24 (Min 19-max 45, IQR = 6) years. Of the 414 nursing students, 287(69%) were single. Concerning years of study of participants, the majority 283 (68.4%) were third years (Table 1).
| Variables category | Frequency | Percent | |
|---|---|---|---|
| Sex | Male | 221 | 53.4 |
| Female | 193 | 46.6 | |
| Age | median \(\pm\) IQR | 24 \(\pm\) 6 | |
| Marital status | Single | 287 | 69 |
| Married | 127 | 31 | |
| Years of study | Third | 283 | 68.4 |
| Fourth | 131 | 31.6 | |
| Learning program | Generic | 286 | 69 |
| Post Basic | 128 | 31 | |
| Department(specialty) | Surgical | 36 | 8.7 |
| Pediatrics | 89 | 21.5 | |
| operation theater | 11 | 2.7 | |
| Emergency | 40 | 9.7 | |
| Neonatal | 27 | 6.5 | |
| Comprehensive | 211 | 51 | |
| Does your father or mother work in the healthcare team | Yes | 55 | 13.3 |
| No | 359 | 86.7 | |
In this study, one–third of nursing students had good knowledge, and 54.3% of them had a positive attitude (Table 2)
| Variables category | Frequency | Percentage(%) | |
|---|---|---|---|
| Have you worked in a health care setting as a nurse before registering for this degree | Yes | 179 | 43.2 |
| No | 235 | 56.8 | |
| Have you ever exposed blood and other body splashes | Yes | 149 | 36 |
| No | 275 | 64 | |
| Have you ever exposed to needle stick injury in your clinical practice | Yes | 104 | 25.1 |
| No | 310 | 74.9 | |
| Knowledge | Good | 134 | 32.4 |
| Poor | 280 | 67.6 | |
| Attitude | Positive | 225 | 54.3 |
| Negative | 189 | 45.7 |
A total of 192(46.4%) nursing students were reported that they had training or seminar on standard precautions in the last six months, and 383(82.9%) of the participants were attached to the pediatric ward (Table 3).
| Variables | Category | Frequency | Percentage (%) |
|---|---|---|---|
| Have your training or seminar on standard precautions in the last six months | Yes | 192 | 46.4 |
| No | 222 | 53.6 | |
| Workplace safety climate | Safe | 80 | 19.3 |
| Unsafe | 334 | 80.7 | |
| Practicum ward | Surgical | 266 | 64.3 |
| Pediatrics | 343 | 82.9 | |
| Medical | 222 | 53.6 | |
| Emergency | 255 | 61.6 | |
| Gyn/obs | 311 | 75.1 |
Among 414 study participants, 56.3% with 95%CI (51.4,60.9) of them were compliant with standard precautions (Fig. 1).
Having good knowledge (AOR = 2.519, 95% CI = 1.609–3.943), Having training or seminar related to standard precautions in the last six months (AOR = 1.518, 95% CI = 1.008–2.288), and Participants perceived workplace climate as safe (AOR = 2.147, 95% CI = 1.242–3.7121) were significantly associated with their compliance (Table 4).
| Variables | Compliance level | COR (95%CI) | AOR (95%CI) | p-value | ||
|---|---|---|---|---|---|---|
| Compliant N | Non-compliant N | |||||
| Gender of the respondent | ||||||
| Male | 106 | 87 | 0.902 (0.611–1.311) | 1.184(0.774–1.813) | 0.436 | |
| Female | 127 | 94 | 1 | 1 | ||
| Age of respondent Continuous | 1.036 (0.986–1.09) | 1.036 (0.970–1.107) | 0.291 | |||
| Marital status | ||||||
| Married | 77 | 50 | 1.311 (0.851–1.991) | 1.048 (0.606–1.813) | 0.867 | |
| Single | 155 | 132 | 1 | 1 | ||
| Study year | ||||||
| 4th year | 66 | 65 | 0.705 (0.465–1.07) | 0.728(.471-1.124) | 0.152 | |
| 3rd year | 167 | 116 | 1 | 1 | ||
| Program | ||||||
| Post basic | 77 | 51 | 1.258 (0.824–1.922) | 1.019 (0.618–1.679) | 0.941 | |
| Generic | 156 | 130 | 1 | 1 | ||
| Nursing Specialty | ||||||
| surgical | 22 | 14 | 1.215 (0.589–2.54) | 0.598 (0.228–1.566) | .0.295 | |
| Pediatrics | 50 | 39 | 0.991 (0.602–1.633) | 0.414 (0.202–0.849) | 0.16 | |
| ORT | 6 | 5 | 0.928 (0.2753.135) | 0.321 (0.075–1.37) | .125 | |
| Emergency | 22 | 18 | 0.945 (0.479–1.865) | 0.370 (0.149–0.920) | 0.32 | |
| Neonatal | 14 | 13 | 0.833 (0.373–1.857) | 0.308 (0.1-0.948) | 0.4 | |
| Comprehensive | 119 | 92 | 1 | 1 | ||
| Have you worked in a healthcare setting as a nurse before registering for this degree? | ||||||
| Yes | 107 | 72 | 1.286 (0.867–1.906) | 1.157 (0.583–2.296) | 0.676 | |
| No | 126 | 109 | 1 | 1 | ||
| Have you ever exposed to needle stick injury in your clinical practice? | ||||||
| Yes | 60 | 44 | 1.08 (0.689–1.692) | 1.230 (0.683–2.216) | .491 | |
| No | 173 | 137 | 1 | 1 | ||
| Have you training or seminar in the last six months | ||||||
| Yes | 121 | 71 | 1.674 (1.129–2.482) | 1.518 (1.008–2.288) | 0.046* | |
| No | 112 | 110 | 1 | 1 | ||
| Have you ever exposed to blood or other body fluids in your clinical practice | ||||||
| Yes | 84 | 65 | 1.006 (0.671–1.508 ) | 0.724 (0.458–1.145) | 0.167 | |
| No | 149 | 116 | 1 | 1 | ||
| Does your father or mother worked in healthcare team | ||||||
| Yes | 31 | 24 | 1.004 (0.566–1.779) | 1.083 (0.571–2.054) | 0.807 | |
| No | 202 | 157 | ||||
| Knowledge of respondents | ||||||
| Good | 95 | 39 | 2.507 (1.614–3.893) | 2.519 (1.609–3.943) | 000* | |
| Poor | 138 | 142 | 1 | 1 | ||
| Attitude of respondents | ||||||
| Positive | 123 | 102 | 0.866 (0.586–1.28) | 0.923 (0.595–1.432) | .721 | |
| Negative | 110 | 79 | 1 | 1 | ||
| Perceived workplace safety climate | ||||||
| Safe | 57 | 23 | 2.225 (1.31–3.779) | 2.147 (1.242–3.712) | 006* | |
| Unsafe | 176 | 158 | 1 | 1 | ||
| Practicum ward | ||||||
| Surgical | Yes | 147 | 119 | 1.123 (0.748–1.686) | 2.684 (0.717–10.04) | 0.143 |
| No | 86 | 62 | 1 | 1 | ||
| Emergency | Yes | 141 | 114 | 1.11 (0.744–1.656) | 1.762 (0.680–4.567) | 0.244 |
| No | 92 | 67 | 1 | 1 | ||
| Medical | Yes | 121 | 101 | 1.169 (0.791–1.726) | 0.735 (0.416–1.299) | 0.29 |
| No | 112 | 80 | 1 | 1 | ||
| Pediatrics | Yes | 186 | 157 | 1.653 (0.967–2.824) | 1.4210 (0.783–2.58) | 0.248 |
| No | 47 | 24 | 1 | 1 | ||
| Gyn/obs | Yes | 169 | 142 | 1.379 (0.874–2.176) | 0.954 (0.453–2.006) | 0.9 |
| No | 64 | 39 | 1 | 1 | ||
| * Variable significant at p-value less than 0.05 | ||||||
| 1 = represents reference group | ||||||
This crossectional study assessed the self-reported compliance with SPs and the factors associated with it among nursing students. Findings of the current study showed that 56.3% with 95%CI (51.4,60.9) of the study participants were compliant with standard precautions.
The finding of this study is in line with studies conducted in Hong Kong 53.5% (27),in Croatia 58.4% (14) and in Saudi Arabia 60.1%, and 56.8% (12, 24) and in Nigeria 57.3 (31). Even though there is a difference in socioeconomic status and level of health sector development, the possible reason for the similarity might be the use of a similar tool and study design.
The finding was lower than studies conducted in South Korea 79.74% (32), 85% in Malaysia (33), Saudi Arabia 61%, and 84.8% (23, 34). The possible reason might be the difference in a hospital setting, sampling techniques, study population characteristics, the availability and accessibility of safety materials (clinical environment), curriculum, and socioeconomic differences. For example, in South Korea sampling techniques were convenient and included only final year nursing students. Additionally, there might be differences in teachers' close monitoring and following up of students during their clinical practices.
However, The result of this study was higher than a study conducted in South Korea 50.5% (13) and in Egypt, 15% of them had good compliance (35). This difference might be the study conducted in South Korea is in a single setting where the current study is a multicenter study and in Egypt sampling technique and sample size difference.
In this study the maximum compliance was on putting used sharp articles into sharps boxes. which is consistence with studies conducted in South Korea (19) and Whereas the lowest compliance in this study was disposing sharps box only when it is full, which is consistent with studies conducted in Croatia (20) and Saudi Arabia (30, 31).
Study participants with good knowledge were found to be 2.52 times more likely to comply with standard precautions as compared to nursing students with poor knowledge (AOR = 2.519, 95% CI = 1.609–3.943). This finding is consistent with the study done in Melanesia (36), China (17) and Iran (37), and Nigeria (38). The possible explanation could be, knowledge is a pre-requisite to appropriate behavioral change and a very important element for behavior change(39). This is also supported by literature that lack of knowledge is the major reason for non-compliance to standard precautions measures (40). So having good knowledge helps to implement standard precautions measures properly as recommended. On the other hand, the finding of the current study Contradicts with the studies in the Philippines (41), Malaysia (33), and South Korea (32) showed that no association between knowledge and compliance.
In the current study participants who had training or seminar related to standard precautions were found to be 1.52 times more likely to be compliant with standard precautions than those who had not taken any training or seminar in the last six months (AOR = 1.518, 95% CI = 1.008–2.288). The current result is consistent with previous literatures in Hong Kong, Saudi Arabia, and Jordan showed that individuals with proper training and education seminar-workshop in infection control are more compliant (17, 23, 24, 42). This might be justified as the fact that training and seminars can sensitize the knowledge of nursing students make them to comply with standard precaution measures. Which also supported by CDC recommendations that training is required for all health care providers to maintain competency and ensure that infection prevention policies and procedures are understood and followed (1).
Participants who perceived workplace climate as safe were found to be 2.15 times more likely to be compliant with standard precautions than those who perceived the workplace as unsafe (AOR = 2.147, 95% CI = 1.242–3.7121). This finding is consistent with the studies conducted in South Korea revealed that the higher the perception of a safe environment for standard precautions results the higher compliance with IPC practices (30, 32). The possible explanation could be well equipped and a safe environment is mandatory to accomplish tasks according to recommendations. Since Safe workplace climate is the shared perception of management for safety support and feedback regarding infection prevention and control in hospitals, including a supportive work environment as well as adequate infrastructure and resources(43). So the health facilities' infection prevention climate needs to be improved to increase students’ compliance with standard precautions.
Generally, nursing students’ compliance with standard precautions was low as compared with CDC and WHO recommendations. Good Knowledge, perceived workplace safety, and having training or seminar in the last six months were significantly associated with being compliant with standard precautions. Great emphasis is required from universities, hospitals as well as police makers.
The use of a self-administered questionnaire may overestimate or underestimate the result of this study. On the other hand, Since It is the first study in Ethiopia among nursing students and it tried to show their compliance clearly.
AOR; Adjusted Odds Ratio, BSc; Bachelor of Science, CI; Confidence Interval, COR; Crude Odds Ratio, CSPs ; Compliance with Standard Precautions Scale, Epi- Info; Epidemiological Information, HAIs; Hospital-Acquired Infections , HBV; Hepatitis B Virus ,HCAIs; Health Care-Associated Infections, HCWs; Health Care Workers, IPC; Infection Prevention and Control, NSs; Nursing Students ,PPE; Personal Protective Equipment ,SPs; Standard precautions ,SPSS; Statistical Package software for Social Sciences ,SPSS; Statistical Package for Social Science, WHO ; World Health Organization
Data sharing statements: All data are available upon reasonable request and the readers could contact the corresponding author.
Ethical declarations
Ethics approval and consent to participate
This study was conducted in accordance with the principles of the Helsinki Declaration. Ethical clearance was obtained from the Research and Ethical Review Committee of the University Gondar College of Medicine and Health Science before the recruitment of study participants with reference no: S/N/164/7/2013. Following approval, a written official letter of cooperation was submitted to each university administration office before the commencement of data collection. After permission had been obtained from each university concerned body, written informed consent was gained from each study participant. Each participating student was informed about the purpose of the study and also informed that about 15- 20 minutes was required to fill a self-administered questionnaire. No personal identification of participants was recorded to ensure confidentiality.
Consent for publication: Not applicable
Acknowledgment
The authors are grateful to all university administrative staff, data collectors, and study participants.
Competing interests: The authors declare that they have no competing interests.
Funding: No funding has been received for the conduct of this study and/or the preparation of this manuscript.
Authors’ contributions
Desalegn Getachew carried out the study starting from conception, analysis, and interpretation of data and reviewing the manuscript. Zewdu Baye participated in proposal writing, data analysis, interpretation, and critical review of the manuscript. Negesu Gizaw participated in reviewing, data analysis, and commenting on the manuscript. Ashenafi worku participated in manuscript preparation and reviewing. All authors are involved in writing, reviewing, and approving the final draft of the manuscript. All authors have taken part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.
Disclosure: The authors report no conflict of interest.